Exam 3 Practice Questions

A pregnant client arrives to the clinic for a prenatal visit appearing uncomfortable. During the assessment, the nurse determines the client is experiencing fairly strong contractions at 12:05 p.m., 12:10 p.m., 12:15 p.m., and 12:20 p.m. What can the nurse conclude from these findings?

a. The client is in active labor.
b. The duration of the contractions is every 5 minutes.
c. The frequency of the contractions is every 5 minutes.
d. The client can be sent home.
Click the card to flip 👆
1 / 43
Terms in this set (43)
A pregnant client arrives to the clinic for a prenatal visit appearing uncomfortable. During the assessment, the nurse determines the client is experiencing fairly strong contractions at 12:05 p.m., 12:10 p.m., 12:15 p.m., and 12:20 p.m. What can the nurse conclude from these findings?

a. The client is in active labor.
b. The duration of the contractions is every 5 minutes.
c. The frequency of the contractions is every 5 minutes.
d. The client can be sent home.
c. The frequency of the contractions is every 5 minutes.

Rationale: there is nothing in the question r/t cervical changes such as dilation or effacement, to be in active labor cervical changes must be present, therefore the answer is simply r/t the frequency of the contractions
The nurse is preparing to teach a group of soon-to-be new parents about the labor process. When detailing the differences between the various presentations, which one should the nurse point out seldom happens?

a. Breech
b. Shoulder
c. Oblique lie
d. Transverse lie
b. Shoulder

Rationale: Shoulder presentations are least likely, 97% of fetuses are born in cephalic presentation at the end of pregnancy, longitudinal lie in which the fetus is parallel to the maternal spine is most common
When teaching a group of nursing students about the different types of pelvis, the nurse describes which features of a gynecoid pelvis? Select all that apply.

a. round-shaped inlet
b. straight sacrum
c. dull ischial spines
d. wide pubic arch
e. convergent side walls
a. rounded-shaped inlet
c. dull ischial spines
d. wide pubic arch

Rationale: Gynecoid pelvis features include oval-shaped inlet, dull ischial spines, wide pubic arch, most favorable pelvis shape. Android pelvis has a straight sacrum and convergent walls
In which situation(s) will the nurse anticipate client admission to the labor and delivery unit? Select all that apply.

a. The client reports experiencing regular contractions every 5 minutes.
b. The nurse notes that the cervix has thinned with 7 cm dilation (dilatation).
c. The client reports a burst of energy and starting the completion of the home nursery.
d. The health care provider has documented pelvic change from the client's last visit.
e. The client reports frequent fetal movements (kicks) throughout the day.
f. The client reports a gush of fluid from the perineal region.
a. p/t reports experiencing regular contractions q5mins
b. nurse notes cervix has thinned with 7cm dilation
d. HCP has document pelvic changes from p/t last visit
f. p/t reports gush of fluid from perineal region

Rationale: anticipated signs of labor included regular contractions q5mins, thinning cervix with progressive dilation, pelvic changes as the cervix thins and dilates, gush of fluid (amniotic fluid) indicating ROM. Fetal movement is a reassuring the fetus is healthy and moving around in the uterus, burst of energy 24-48hrs before the onset of labor is common, she may have the energy or desire to complete a big project in anticipation of NB arrival, woman should be cautioned to conserve energy for labor, report of a burst of energy alone is NOT a reason to admin p/t to L&D unit
As a woman enters the second stage of labor, which would the nurse expect to assess?

a. feelings of being frightened by the change in contractions
b. reports of feeling hungry and unsatisfied
c. falling asleep from exhaustion
d. expressions of satisfaction with her labor progress
a. feelings of being frightened by the change in contractions

Rationale: nature of contractions change drastically, urge to push becomes very strong → this can be frightening
The nurse is caring for a client in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is:

a. 7.15 or less.
b. 7.25 or more.
c. 7.20.
d. 7.21
a. 7.15 or less

Rationale: pH < 7.2 = hypoxic fetus, indicative of fetal distress
There has been much research done on pain and the perception of pain. What is the result of research done on levels of satisfaction with the control of labor pain?

a. Women report higher levels of satisfaction when regional anesthetics are used to control pain.
b. Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience.
c. Women report higher levels of satisfaction when the primary care provider makes the decision on what type of pain control to use.
d. Women report higher levels of satisfaction when different types of relaxation techniques are used to control pain.
b. women report higher levels of satisfaction when they felt they had high degree of control over pain experience

Rationale: being involved in pain management and adequate control of pain is an important factor in overall labor experience, women report that its not the amount of pain they experience during labor but how its is managed
A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize?

a. maternal hypotension and fetal tachycardia
b. maternal hypertension and fetal bradycardia
c. maternal hypotension and fetal bradycardia
d. maternal hypertension and fetal tachycardia
c. maternal hypotension and fetal bradycardia

Rationale: epidural poses an AE of hypotension especially if p/t has not received enough fluids before procedure, hypotension can cause uterine hypoperfusion resulting in fetal bradycardia
A nurse is caring for a client who has had a cesarean birth with general anesthesia. The nurse would assess the woman closely for which possible complication?

a. maternal hypotension
b. inadequate pain block
c. pruritus
d. uterine atony
d. uterine atony

Rationale: complication of general anesthesia is relaxation of uterine muscles leading to uterine atony and possible risk for PPH. Maternal hypotension, failed block, and pruritus are AE of epidural
During stage 3 of labor, you note a gush of blood and that the uterus changes shape from an oval shape to globular shape. This indicates?

a. Postpartum hemorrhage
b. Imminent delivery of the baby
c. Signs of placental separation
d. Answers B and C
c. Signs of placental separation

Rationale: Signs that the placenta is about to be delivered or "seperate" include Umbilical cord starts to lengthen, Trickling/gush of blood, and uterus changes from an oval shape to globular
True or False: Stage 2 of labor begins with the delivery of the baby and ends with the delivery of the placenta. a. True b. Falseb. False Rationale: Stage 2 begins with the full dilation of the cervix (10 cm) and ends with the full delivery of the baby.A client is admitted to the health care facility. The fetus has a gestational age of 42 weeks and is suspected to have cephalopelvic disproportion. Which should the nurse do next? a. Place the client in lithotomy position for birth. b. Administer oxytocin intravenously at 4 mU/minute. c. Perform artificial rupture of membranes. d. Prepare the client for a cesarean birth.d. Prepare the client for a cesarean birth. Rationale: Cephalopelvic disproportion is associated with postterm pregnancy. This client will not be able to vaginally give birth and should be prepared for a cesarean birth. Lithotomy position, artificial rupture of membranes, and oxytocin are interventions for a vaginal birth.A primigravida at 28 weeks' gestation comes to the clinic for a checkup. She tells the nurse that her mother gave birth to both of her children prematurely, and she is afraid that the same will happen to her. Which risk factors associated with preterm birth would the nurse discuss with the client? Select all that apply. a. history of previous preterm birth b. current multiple gestation pregnancy c. large-for-gestational-age fetus d. uterine or cervical abnormalities e. previous cesarean birtha. history of previous preterm birth b. current multiple gestation pregnancy d. uterine or cervical abnormalities Rationale: The top three risk factors for premature birth are history of previous preterm birth, current multiple gestation pregnancy, and uterine or cervical abnormalities.The nurse is examining a client at 37 weeks' gestation who came to labor and delivery with severe cramps and vaginal spotting. While listening to the fetal heart rate the nurse observes a reddened area of the side of the client's abdomen. When the nurse asks about the area, the client says "I got hit with a broom." The nurse asks who hit her, but the client does not respond. A vaginal examination reveals the cervix is 50% effaced and dilated 1 cm, membranes are intact, no bleeding and the presenting part is floating. Based on the nurse's assessment, the client is admitted to the observation unit to be monitored for which obstetrical condition? a. Placental abruption (abruptio placentae) b. Preeclampsia c. Premature labor d. Placenta previaa. Placental abruption (abruptio placentae) Rationale: Trauma to the abdomen increases the risk for placenta abruption (abruptio placentae). The client's presentation with severe cramps is consistent with a potential for placental abruption. The client is at 37 weeks' gestation so she is not in premature labor. A placenta previa would present with painless vaginal bleedingA woman in labor is having very intense contractions with a resting uterine tone >20 mm Hg. The woman is screaming out every time she has a contraction. What is the highest priority fetal assessment the health care provider should focus on at this time? a. Monitor heart rate for tachycardia. b. Monitor fetal movements to ensure they are neurologically intact. c. Look for late decelerations on monitor, which is associated with fetal anoxia. d. Monitor fetal blood pressure for signs of shock (low BP, high FHR).c. Look for late decelerations on monitor, which is associated with fetal anoxia. Rationale: A danger of hypertonic contractions is that the lack of relaxation between contractions may not allow optimal uterine artery filling; this can lead to fetal anoxia early in the latent phase of labor. Applying a uterine and a fetal external monitor will help identify that the resting phase between contractions is adequate and that the FHR is not showing late deceleration.The nurse is assessing a multipara client who presents to the hospital after approximately 2 hours of labor and notes the fetus is in a transverse lie. After notifying the RN and primary care provider, which action should the LPN prioritize? a. Include a set of piper forceps when the table is prepped. b. Apply pressure to the client's lower back with a fisted hand. c. Assist with nitrazine and fern tests. d. Prepare to assist with external version.d. Prepare to assist with external version. Rationale: Transverse lie is a fetal malposition and is a cause for labor dystocia. The fetus would need to be turned to the occipital position using external version or be born via cesarean birth. Piper forceps are used in the birth of a fetus that is in the breech position. Nitrazine and fern tests are done to assess if amniotic fluid is leaking from the sac into the vagina. Counterpressure applied to the lower back with a fisted hand sometimes helps the client to cope with the "back labor" that is characteristic of occiput posterior (OP) positioning.A woman has been in labor for the past 8 hours, and she has progressed to the second stage of labor. However, after 2 hours with no further descent, the provider diagnoses "arrest of labor." The woman asks, "Why is this happening?" Which response is the best answer to this question? a. "Maybe your uterus is just tired and needs a rest." b. "It is likely that your body has not secreted enough hormones to soften the ligaments so your pelvic bones can shift to allow birth of the baby." c. "Maybe your baby has developed hydrocephaly and the head is too swollen." d. "More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal."d. "More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal." Rationale: Arrest of labor results when no descent has occurred for 2 hours in a nullipara or 1 hour in a multipara. The most likely cause for arrest of descent during the second stage is CPD.A client is 2 weeks past her due date, and her health care provider is considering whether to induce labor. Which conditions must be present before induction can take place? Select all that apply. a. The fetus is in a longitudinal lie. b. The cervix is ripe. c. A presenting part is engaged. d. Cephalopelvic disproportion is present. e. Maternal blood pressure is normal. f. There is absence of eclampsia.a. The fetus is in a longitudinal lie. b. The cervix is ripe. c. A presenting part is engaged. Rationale: Before induction of labor is begun in term and postterm pregnancies, the following conditions should be present: the fetus is in a longitudinal lie; the cervix is ripe, or ready for birth; a presenting part is engaged; there is no cephalopelvic disproportion; and the fetus is estimated to be mature by date (over 39 weeks) or demonstrated by a lecithin-sphingomyelin ratio or ultrasound biparietal diameter to rule out preterm birth. Normal maternal blood pressure and absence of eclampsia are not conditions required for induction; in fact, severe hypertension and eclampsia are conditions that may necessitate induction.A G3P2 woman at 39 weeks' gestation presents highly agitated, reporting something "came out" when her membranes just ruptured. Which action should the nurse prioritize after noting the umbilical cord is hanging out of the vagina? a. Put the client in bed immediately, call for help, and lift the presenting part of the fetus off the cord. b. With the client in lithotomy position, hold her legs and sharply flex them toward her shoulders. c. Place the client in Trendelenburg position and gently attempt to reinsert the cord. d. Contact the health care provider and prepare the client for an emergent vaginal birth.a. Put the client in bed immediately, call for help, and lift the presenting part of the fetus off the cord. Rationale: The nurse must put the woman in a bed immediately, while calling for help, and holding the presenting part of the fetus off the cord to ensure its safety. Umbilical cord prolapse occurs when the umbilical cord slips down in front of the presenting part, which can result in the presenting part compressing the cord, cutting off oxygen and nutrients to the baby, and the baby is at risk of death. This is an emergency. When a prolapsed cord is evident the nurse does not put the woman in lithotomy position, and cannot attempt to reinsert the cord. A vaginal birth is contraindicated in this situation.Upon examination, a nurse notes that a woman is 10 cm dilated, 100% effaced, and −3 station. Which of the following actions should the nurse perform during the next contraction? 1. Encourage the woman to push. 2. Provide firm fundal pressure. 3. Move the client into a squat. 4. Monitor for signs of rectal pressure.4. Monitoring for rectal pressure is appropriate at this time. TEST-TAKING TIP: Pushing a baby that is not yet engaged may result in an overly fatigued woman or, more significantly, a prolapsed cord. All other interventions are r/t to pushing with mother is not ready for yet in this situation d/t negative stationA nurse is educating a pregnant woman regarding the moves a fetus makes during the birthing process. Please place the following cardinal movements of labor in the order the nurse should inform the client that the fetus will make: 1. Descent. 2. Expulsion. 3. Extension. 4. External rotation. 5. Internal rotation.1, 5, 3, 4, 2. The correct order of the movements listed is: 1. Descent. 5. Internal rotation. 3. Extension. 4. External rotation. 2. Expulsion. TEST-TAKING TIP: cardinal moves of labor. First, descent and flexion must occur. If the baby does not descend into the birth canal and the baby does not flex the head so that his or her chin ison the chest, the baby simply will not be able to traverse through the bony pelvis. Second, internal rotation (rotation of the fetal body when the fetal head is still inside the mother's pelvis) must occur before external rotation (rotation of the fetal body after the fetal head is outside the mother). In between the rotational moves is extension, the delivery of the head. And, finally, expulsion must be last because the delivery of the baby's body is simply the last movement.While performing Leopold's maneuvers on a woman in labor, the nurse palpates a hard round mass in the fundal area, a flat surface on the left side, small objects on the right side, and a soft round mass just above the symphysis. Which of the following is a reasonable conclusion by the nurse? 1. The fetal position is transverse. 2. The fetal presentation is vertex. 3. The fetal lie is vertical. 4. The fetal attitude is flexed.3. The fetal lie is vertical. Rationale: With the findings of a hard round mass in the fundal area and soft round mass above the symphysis, the nurse can conclude that the fetal lie is vertical. The attitude is difficult to determine when performing Leopold maneuvers.On examination, it is noted that a full-term primipara in active labor is right occipi- toanterior (ROA), 7 cm dilated, and +3 station. Which of the following should the nurse report to the physician? 1. Descent is progressing well. 2. Fetal head is not yet engaged. 3. Vaginal delivery is imminent. 4. External rotation is complete.1. Descent is progressing well. Descent is progressing well. The presenting part is 3 centimeters below the ischial spines, fetal head is well past engagement. The woman, a primipara, is only 7 centimeters dilated. Delivery is likely to be many hours away, external rotation does not occur until after delivery of the fetal headA client who is 7 cm dilated and 100% effaced is breathing at a rate of 50 breaths per minute during contractions. Immediately after a contraction, she complains of tingling in her fingers and some light-headedness. Which of the following actions should the nurse take at this time? 1. Assess the blood pressure. 2. Have the woman breathe into a bag. 3. Turn the woman on her side. 4. Check the fetal heart rate.2. Have the woman breathe into a bag. Rationale: p/t showing signs of hyperventilation. The symptoms will likely subside if she rebreathes her exhalations. The baby is not in jeopardy at this time. This client is light- headed as a result of being tachypneic during contractions. Hyperventilation, which can result from tachypnea, is characterized by tingling and light- headedness. Rebreathing her air should rectify the problem.The nurse is assessing a client who states, "I think I'm in labor." Which of the following findings would positively confirm the client's belief? 1. She is contracting q 5 min × 60 sec. 2. Her cervix has dilated from 2 to 4 cm. 3. Her membranes have ruptured. 4. The fetal head is engaged.2. Her cervix has dilated from 2 to 4 cm. Rationale: Once the cervix begins to dilate, a client is in true labor, engagement can occur before true labor begins, contractions alone are not an indicator of true labor. Only when the cervix dilates is the client in true labor.A gravid client at term called the labor suite at 7:00 p.m. questioning whether she was in labor. The nurse determined that the client was likely in labor after the client stated: 1. "At 5:00 p.m., the contractions were about 5 minutes apart. Now they're about 7 minutes apart." 2. "I took a walk at 5:00 p.m., and now I talk through my contractions easier than I could then." 3. "I took a shower about a half hour ago. The contractions seem to hurt more since I finished." 4. "I had some tightening in my belly late this afternoon, and I still feel it after waking up from my 2-hour nap."3. "I took a shower about a half hour ago. The contractions seem to hurt more since I finished." Rationale: This response indicates that the labor contractions are increasing in intensity.obstetric conjugateshortest anterior to posterior diameter of the pelvis. When it is of average size, it will accommodate an average-sized fetal head.During delivery, the nurse notes that the baby's head has just been delivered. The nurse concludes that the baby has just gone through which of the following cardinal moves of labor? 1. Flexion. 2. Internal rotation. 3. Extension. 4. External rotation.3. Extension. Rationale: During extension, the baby's head is birthed.The nurse is interpreting the fetal monitor tracing below. Which of the following actions should the nurse take at this time? 1. Provide caring labor support. 2. Administer oxygen via tight-fitting face mask. 3. Turn the woman on her side. 4. Apply the oxygen saturation electrode to the mother.1. Provide caring labor support. Rationale: A tracing showing moderate variability—that is, 6 to 25 bpm wide—indicates adequate variability and this, in turn, indicates normal pH and oxygenation of the fetus, MODERATE = GOOD, no intervention required, just supportive careA woman is in active labor and is being monitored electronically. She has just received Stadol 2 mg IM for pain. Which of the following fetal heart responses would the nurse expect to see on the internal monitor tracing? 1. Variable decelerations. 2. Late decelerations. 3. Decreased variability. 4. Transient accelerations.3. Decreased variability. Rationale: The analgesics used in labor are opiates. The CNS-depressant effect of the opiates is therapeutic for the mother who is in pain, but the baby is also affected by the medica- tion, often exhibiting decreased variability.A woman is in the second stage of labor with a strong urge to push. Which of the following actions by the nurse is appropriate at this time? 1. Assess the fetal heart rate between contractions every 60 minutes. 2. Encourage the woman to grunt during contractions. 3. Assess the pulse and respirations of the mother every 5 minutes. 4. Position the woman on her back with her knees on her chest.2. Encourage the woman to grunt during contractions. Rationale: glottis breathing during second stage involves grunting during contractions to prevent vasovagal responseDuring the third stage of labor, the following physiological changes occur. Please place the changes in chronological order. 1. Hematoma forms behind the placenta. 2. Membranes separate from the uterine wall. 3. The uterus contracts. 4. The uterine surface area dramatically decreases.3, 4, 2, 1 Rationale: Once the baby is born, the uterus contracts. When it does so, the surface area of the internal uterine wall decreases, forcing the placenta to begin to separate. As the placenta separates, a hematoma forms behind it, further promoting placental separationA G1 P0, 8 cm dilated, is to receive pain medication. The healthcare practitioner has decided to order an opiate analgesic with a medication that reduces some of the side effects of the analgesic. Which of the following medications would the nurse expect to be ordered in conjunction with the analgesic medication? 1. Seconal (secobarbital). 2. Phenergan (promethazine). 3. Stadol (butorphanol). 4. Tylenol (acetaminophen).2. Phenergan (promethazine). Rationale: Promethazine increases the effectiveness of the analgesic but also because it acts as an antiemetic, decreases N/V, and is an anxiety reducer.A client, G2 P1001, 5 cm dilated and 40% effaced, has just received an epidural. Which of the following actions is important for the nurse to take at this time? 1. Assess the woman's temperature. 2. Place a wedge under the woman's side. 3. Place a blanket roll under the woman's feet. 4. Assess the woman's pedal pulses.2. Place a wedge under the woman's side. Rational: hypotension is the most common complication of epidural anesthesia in labor d/t compression of the vena cava by the pregnant uterus, placed under the woman's side— usually the right side—the uterus is tilted to the left relieving the pressure on the great vessels to prevent supine hypotensionthe nurse is providing acupressure for pain relief to a woman in labor. Where is the best location for the acupressure to be applied? Select all that apply. 1. On the malleolus of the wrist. 2. Above the patella of the knee. 3. On the medial aspect of the lower leg. 4. At the top one-third of the sole of the foot. 5. Below the medial epicondyle of the elbow.3, 4 Rationale: Complementary therapies, pressure applied on the medial surface of the lower leg and to the depression at the top one third of the sole of the foot has been shown to lessen the pain of labor.Between contractions, a client in the active phase of labor states, "Not only do these contractions really hurt me, but what are they doing to my baby? I am so scared and I can't stop thinking about how my baby might be hurting, too." The patient requests medication to reduce her pain. It would be most appropriate for the nurse to suggest the client's primary healthcare provider to order which of the following labor pain-relieving methods? 1. Epidural. 2. Nitrous oxide. 3. Narcotic analgesic. 4. Spinal.2. Nitrous oxide. Rationale: epidural anesthesia will relieve the client's pain, it will not act to reduce the client's fears, during labor, inhaled nitrous oxide exerts both a pain-relieving action as well as an anxiety-reducing action, self-administered nitrous oxide has been shown to be an effective pain-relieving medication especially in women who exhibit anxiety or fear during laborA client has been diagnosed with water intoxication after having received IV oxytocin (Pitocin) for over 24 hours. Which of the following signs/symptoms would the nurse expect to see? 1. Confusion, drowsiness, and vomiting. 2. Hypernatremia and hyperkalemia. 3. Thrombocytopenia and neutropenia. 4. Paresthesias, myalgias, and anemia.1. Confusion, drowsiness, and vomiting. Rationale: classic s/s of intoxication confusion, drowsiness, vomiting, depression of VS, hyponatremia and hypokalemiaA 40-week-gestation woman has received Cytotec (misoprostol) for cervical ripening. For which of the following signs/symptoms should the nurse carefully monitor the client? 1. Diarrhea and back pain. 2. Hypothermia and rectal pressure. 3. Urinary retention and rash. 4. Tinnitus and respiratory distress.1. Diarrhea and back pain. Rationale: (misoprostol)is a synthetic prostaglandin medication used to ripen the cervix for induction, side effects include diarrhea and back pain, uterine tetanyThe physician has ordered Prepidil (dinoprostone) for four gravidas at term. The nurse should question the order for which of the women? 1. Primigravida with Bishop score of 4. 2. Multigravida with late decelerations. 3. G1 P0000 contracting every 20 minutes × 30 seconds. 4. G6 P3202 with blood pressure 140/90 and pulse 92.2. Multigravida with late decelerations. Rationale: A primipara with a Bishop score of 4 cannot be induced without intervention, Cervidil helps to improve cervical readiness for an oxytocin induction. This client's fetus showing signs of fetal distress indicates increased risk of fetal injury with induction DO NOT induce with fetal distress, malpositioningA client, G4 P1021, has been admitted to the labor and delivery suite for induction of labor. The following assessments have been made: Bishop score of 2, fetal heart rate of 156 with good variability and no decelerations, TPR 98.6°F, P 88, R 20, BP 120/80, negative obstetric history. Cervidil (dinoprostone) has been inserted. Which of the following findings would warrant the removal of the prostaglandin? 1. Bishop score of 4. 2. Fetal heart rate of 152. 3. Respiratory rate of 24. 4. Contraction frequency of 1 minute.4. Contraction frequency of 1 minute. Rationale: frequency of UC is 1 minute (an example of tachysystole), which means p/t is in labor and placenta only has a short period to recovery before the next UC, not enough time to be sufficiently perfused. Fetal bradycardia is a likely outcome to such a short frequency period.The nurse is to intervene when caring for a laboring client whose baby is exhibiting signs of fetal distress. Which of the following actions should the nurse take? 1. Administer oxygen via nasal cannula. 2. Place the client in high Fowler position. 3. Remove the internal fetal monitor electrode. 4. Increase the intravenous infusion rate.4. Increase the intravenous infusion rate. Rationale: admin oxygen via NC, increase IV rate helps to improve perfusion to the placenta.A full-term client, contracting every 15 min × 30 sec, has had ruptured membranes for 20 hours. Which of the following nursing interventions is contraindicated at this time? 1. Intermittent fetal heart auscultation. 2. Vaginal examination. 3. Intravenous fluid administration. 4. Nipple stimulation.2. Vaginal examination. Rationale: prolonged ROM increases risk for infection, vaginal examination increases the chance for infection. Nipple stimulation would be APPROPRIATE to simulate laborA woman being induced with oxytocin (Pitocin) is contracting every 3 min × 30 seconds. Suddenly the woman becomes dypsneic and cyanotic and begins to cough up bloody sputum. Which of the following nursing interventions is of highest priority? 1. Check blood pressure. 2. Assess fetal heart rate. 3. Administer oxygen. 4. Stop oxytocin infusion.3. Administer oxygen. Rationale: The nurse's priority action is to administer oxygen. It is appropriate to stop the infusion, but that is not the priority action. This client is exhibiting the classic signs of an amniotic fluid embolism. At this point, the baby's health is secondary because the mother is in a life-threatening situation. The nurse must apply oxygen and call a code immediately.